Dramatic Inflammatory Regression of Choroidal Metastases from Renal Cell Carcinoma Following Ipilimumab and Nivolumab Immunotherapy: A Case Series

Introduction: Renal cell carcinoma (RCC) is a rare cause of ophthalmic metastasis. Immune checkpoint blockers (ICBs) such as ipilimumab and nivolumab (ipi/nivo) are first-line therapies for advanced RCC. There are limited efficacy reports of ICBs for RCC choroidal metastases (CM). Case One: A 43-year-old male with metastatic (lung) clear cell RCC presented with left eye scleritis and a 3.4mm choroidal mass. One week after starting ipi/nivo, the lesion rapidly expanded to 11.9mm with vitritis, subtotal exudative retinal detachment (ERD), and features of necrosis (heterogenous echogenicity). The lesion regressed over 10 months to 1.29mm with resolution of ERD and improved visual acuity from counting fingers to 20/50. Case Two: A 63-year-old male with clear cell RCC presented with a right eye 7.2mm choroidal mass and subretinal hemorrhage. The lesion enlarged to 10.9mm with ERD and heterogenous echogenicity after starting ipi/nivo, which then regressed to 2.4mm by seven months, leaving retinal folds. Vision declined to hand motions and remained stable. Conclusion: Ipi/nivo can induce rapid and sustained regression of RCC CM, but may cause profound intraocular inflammation, collateral damage to surrounding structures, and subsequent vision loss. This response may be enhanced in the presence of preexisting scleritis.